The north-south policy divide in transnational healthcare: a comparative review of policy research on medical tourism in source and destination countries

Health systems around the world are experiencing common challenges. Long wait times, tightening eligibility restrictions, narrowing service offerings, fiscal and human resource shortages, and changing demographic profiles and disease burdens have made it difficult for governments to effectively meet the healthcare needs of citizens. Medical tourism has emerged as one of many solutions, made possible by transnational mobility of information, ideas, expertise, people and capital, and growing consumerism in healthcare. Globalization has led to high levels of standardization of medical knowledge, practice protocols and technologies, allowing patients in high-income countries to obtain timely, high-quality and affordable treatment through healthcare providers in other countries. Developing countries too have tapped into the growing popularity of medical tourism to develop their economies. Healthcare providers in destination countries and their brokers have, for instance, taken advantage of the internet to market their services to international consumers [1]. Countries like India and Thailand have intentionally linked medical care with tourism in their messaging, to leverage their reputations as leisure destinations [2]. Healthcare providers in Argentina have pitched their own distinctive brand, through association with cultural motifs like the ‘tango’ in online advertisements [3]. The extent to which destination countries have benefited has hinged on their ability to integrate global technologies and knowhow with unique domestic advantages.

The use of medical tourism as a welfare and developmental strategy is nonetheless contested. Its role in bridging health system deficiencies, improving healthcare standards and stimulating local economies has been long recognized, but there is increasing awareness in recent years of the ways in which it can burden public resources and deepen health inequities, often at the cost of marginalized populations [4‐7]. Medical tourism is therefore an important action arena for policymaking, necessitated not just by the need to encourage the industry, but also to minimize its socioeconomic discontents, and to address its ethical and legal challenges, both in countries from which medical tourists originate, and in those they seek healthcare [8‐10].

Despite these concerns, most countries lack explicit strategies on deploying medical tourism towards defined policy goals. Decisions on the transfer of medical technologies, foreign investment in health, immigration laws for healthcare professionals and visa provisions for overseas patients are often negotiated as part of international trade agreements, with little coordination across policy subsystems, or convergence between sectoral policies despite their obvious interconnectedness [11, 12]. Consider the case of India, for example. While there have been concerted attempts to attract medical tourists, simplify visa processes, publicize domestic healthcare providers internationally and regulate medical travel agencies, these efforts have mostly focused on the promotional aspects and on streamlining the tourism experience, which while important, do not address macro policy issues such as capacity deficits, spillover effects and incongruities between sectoral policies [13, 14]. The background document for India’s National Health Policy makes no mention of medical tourism, nor does the ensuing policy engage with issues emerging from it, although India is a major regional hub, and the development of its private health sector has been greatly influenced by it [15, 16]. Likewise, the policy on M-visas is determined by the Ministry of External Affairs, with little input from the Ministry of Health and Family Welfare on absorption capacity and effects on local health systems.

Poor availability of data is another challenge [17]. A large number of medical tourists travel on ordinary tourist visas to avoid cumbersome bureaucratic procedures, keeping a significant portion of medical tourism activity outside the purview of policymakers who might otherwise find such information invaluable [18]. There are definitional variations and no standardized method for collating data on global medical travel [19]. National databases that serve to evaluate health policies and programs, do not typically capture information on the nature and quantum of transnational transactions in medical services. Even in Canada, which has a strong tradition of evidence-informed policymaking, the major databases maintained by the Canadian Institute for Health Information (CIHI) and Statistics Canada, do not provide information on publicly funded out-of-country care (OOCC) sought abroad privately as medical tourists [20]. The Canadian Longitudinal Study on Aging (CLSA) includes a variable on international travel for leisure, but not for healthcare – despite the fact that consumers of medical tourism services are typically elderly. As a result, policymakers often do not have the informational means and empirical foundations for mapping the contours of the industry, or for making reliable assessments of its systemic and network effects in source and destination countries, leading to patchy policymaking [21]. That this issue remains at the periphery of governmental strategic thinking and a neglected policy area despite its public significance, is surprising.

While recent research has identified global themes in medical tourism research [22, 23], transnational differences in policy and policy research on this subject have been less explored. Medical tourism occupies different spaces within the national policy landscapes of countries, depending on which side of the transnational paradigm they belong to, and how they seek to leverage it towards their goals. In this article, we draw attention to this policy divide through a comparative review of policy research on medical tourism in select source (Canada, United States [US] and United Kingdom [UK]) and destination countries (Mexico, India, Thailand, Malaysia and Singapore). These countries are among the major hubs of medical tourism activity and the focus of significant empirical research in the field in recent years. We identify themes that scholars have sought to address, and their relative prominence in policy-related research on these countries. Based on our review, we assess cross-national differences in policy and policy research on medical tourism against contextual policy landscapes and challenges, and identify research-policy gaps.

The review was conducted using the PRISMA (Preferred reporting Items for Systematic review and Meta-Analyses) process flow developed by Moher, Liberati et al. [24] (Fig. 1). A Boolean search of the Web of Science (WoS) Core Collection was performed between October and November 2018 to sequentially identify policy-related publications on medical tourism in the selected countries for all years till date. The search was limited to the WoS database due to the technical challenges of multi-source comparative analyses and to facilitate more in-depth analysis of the materials identified. We covered both open access and subscription based publications. We included journal articles, reviews, books, book chapters, conference proceedings, editorial material, trade publications and industry reports, but excluded reprints, book reviews, news articles, letters, meeting abstracts, short surveys, conference reviews, errata, bibliographies and notes. No language or geographical restrictions were applied to search results.

The initial search identified publications on medical tourism (step 1). The search was then repeated to isolate the subset of publications on policy (step 2). A final search was conducted to shortlist publications specifically referencing select source (Canada, US and UK) and destination countries (Mexico, India, Thailand, Malaysia and Singapore) (step 3).¹ Records were screened for duplicity and relevance, and those found not relevant were removed following each search iteration. Relevance was assessed qualitatively through a review of publication titles and abstracts (or full texts when these were either ambiguous or insufficient) based on three criteria – whether the materials explicitly dealt with medical tourism, whether they (directly or indirectly) addressed policy-related aspects, and whether they were rooted in the contexts of the selected countries or contributed to their understanding. Publications that met all the three criteria were included in the final shortlist. Those only tangentially alluding to but not substantively engaging with them were excluded. The studies included in the bibliometric review based on appraisal of the context country, study objectives and main conclusions are outlined in Additional file 1 uploaded as electronic supplementary material. The bibliographic data was imported into a data visualizing software called VOSviewer to create and visualize a network map of research themes covered.

In addition, we searched Google and Google Scholar search engines, and database archives such as the Public Affairs Information Service (PAIS) Index, PolicyArchive, IssueLab and Factiva for grey literature on policy issues related to medical tourism in the selected countries (step 4). These included government agency reports, position papers, industry publications, thinktank analyses and news articles. Results from this last step (not shown in Fig. 1) were not included in the bibliometric review, but were rather used to supplement our interpretation of different problem and policy contexts, and juxtapose the identified policy research against them.

Out of the 1224 publications focused on medical tourism, 62 publications explicitly address policy with reference to one or more of the 8 selected countries (Canada, US, UK, Mexico, India, Thailand, Malaysia and Singapore). Figure 2 maps the key themes that scholars have sought to address, and their relative prominence in research with respect to each country. Table 1 juxtaposes this research against the key policy challenges that source and destination countries are faced with. Based on our review, we identify cross-national patterns in policy research, and highlight synergies and gaps in research and policy.

These limitations notwithstanding, some interesting comparative insights are offered by the study. Firstly, we see major differences in national policy concerns, not only between source and destination countries, but also among them, given their unique socio-political contexts, developmental pressures and policy challenges. The diversity in policy research reflects their different realities (Table 1). How policymakers approach issues of cross-border healthcare, depends on which side of the transnational divide countries are located on, and how they seek to leverage the potential of medical tourism for the achievement of national policy goals.

Policymaking in destination countries is mostly directed towards developing supply-side capacities and competitiveness, without being particularly attentive to the distortionary effects on local health systems and the regulatory weaknesses that engender them. For instance, the governments of Mexico, India, Thailand and Malaysia have focused much of their policy attention, economic resources and governance capacities on promoting their provinces as destinations for low-cost medical tourism, incentivising private sector operators to strengthen medical and tourism infrastructure for medical tourists, and addressing regulatory hurdles for investors and consumers, often neglecting the health needs and wellbeing of their own populations, and the safety of medical tourists.

Source country policies, on the other hand, are designed to facilitate outbound medical travel to overcome domestic health system deficiencies and assure care standards in destination countries, while doing little to address the discriminatory application of ethical and regulatory norms to medical travel to those countries, or fix the issues that drive the exodus. Policymaking in the US, for example, has focused less on resolving the structural issues that limit healthcare access and coverage within the US, and more on establishing cross-border insurance mechanisms, transnational cost-saving arrangements and global networks of accredited healthcare providers to enable travel for treatment overseas. In the UK, a recent amendment to Northern Ireland’s abortion law has now made abortion services universally accessible. At the same time, however, both Canadian and UK laws for the regulation of transnational surrogacy and transplant tourism remain weak and ineffective in protecting surrogate mothers and organ donors in destination countries from exploitation.

The lop-sidedness in government priorities has skewed the narrative on medical tourism from that of a catalyst for socioeconomic development, health sector improvement and universal health coverage to a vehicle for economic growth and healthcare outsourcing. This divergence has created policy overlaps, tensions and fault lines between the Global North and South. While there is cross-national directional convergence in efforts to facilitate the travel of medical tourists, there remain critical gaps that cause treatment complications and hamper continuity of care in source countries, disadvantage vulnerable groups in destination countries, and create health inequities between source and destination countries. Addressing these requires the development of a global framework for the collaborative governance and enforcement of transnational processes of medical tourism, and mechanisms for policy coordination and regulatory convergence between source and destination countries to ensure policy alignment. It follows therefrom that policymakers need to explicitly consider what they seek to achieve through medical tourism in the context of their developmental goals, and purposively design a policy architecture that optimizes their gains and minimizes risks across the value chain. In source countries, this might, for example, involve legislative changes to facilitate extraterritorial application of protective provisions to prevent exploitation, and rationalization of regulatory restrictions and health system reforms to reduce the need for citizens to travel abroad for treatment. In destination countries, it might include cross-subsidization arrangements to transmit resources internally, incentive and regulatory regimes to control brain drain, and capacities to assure care quality and continuity through standardized treatment protocols, certification systems and networked electronic medical record exchange. It is notable that Singapore has been defter at navigating this divide. It has better addressed source country concerns on safety and quality of care as compared to its peers, and at the same time taken steps to insulate its health system from the unintended consequences of medical tourism. Its inward-focused and pragmatic policy approach may have potentially contributed to shielding it from some of the same problems that other destination countries have encountered, even as it has successfully managed to maintain its unique market position within the region.

Second, we find that research and policy are not always congruent. There are several areas where there are gaps from research being out of step with prevailing policy concerns. For instance, policy research in Canada is focused on drawing attention to the ethical and medicolegal concerns of medical tourism, and its undermining effects on access and equity, but does not adequately address the inherent weaknesses of the Canadian healthcare system that compel Canadians to seek treatment overseas, or the regulatory underpinnings that give rise to ethical conflicts. Likewise, there are areas where the policy discourse has failed to take heed of relevant policy research. In the UK, resistance to skilled worker immigration despite the high dependence of the NHS on foreign medical professionals, and the narrative driving policy against healthcare coverage for migrants despite lack of empirical evidence on systematic abuse, is a case in point. While it is well-recognized that policy and research seldom fully converge since the political economies that shape them operate autonomously and are slightly different, major incongruencies, like those mentioned above, can be mediated through better channels for collaboration and communication between researchers, policymakers and interest groups. Internationally, and especially in the health sector, knowledge platforms and policy labs are playing an increasingly important role in widening the evidence base for public policy through analytical inputs to help governments formulate better policy responses, building trust and confidence among diverse stakeholders, and co-producing research that is relevant to policymaking needs [109, 110]. Such initiatives in the medical tourism sector could go a long way in strengthening research-policy linkages, addressing obvious gaps in research and policy, and facilitating effective uptake of research by governments. Canada, for example, has a strong tradition of evidence-informed policymaking, and initiatives such as the McMaster Health Forum have contributed immensely to deliberative dialogues between health researchers, providers, managers and policymakers to optimize the use of research evidence in policymaking and practice [111]. These mechanisms can be leveraged for greater coordination between medical tourism policy and research. Beyond research-policy linkages, UK’s example of how political considerations can sometimes get the better of empirically-grounded policy advice, highlights the need for greater technocratic control over decision-making to the extent possible in democratic systems. While the role of political triggers in policymaking cannot be ignored, formal institutionalization of research into policymaking processes can help better insulate them from extraneous political influences and minimize political risk.

Our final point relates to the amenability of medical tourism research to a comparative policy perspective (Fig. 3). Consider, for example, the processes of diffusion that have helped countries supplying medical tourism services to optimize costs, upgrade technology, develop skills and knowhow, strengthen capacity and raise quality standards. The contagious character of globalization is likewise responsible for the widespread acceptance of the western biomedical concept of health, replication of clinical best practices, research advancements in new treatments and technologies, establishment of accreditation standards and certification systems, adoption of quality improvement methodologies by healthcare organizations, and cross-pollination of alternative systems like Homoeopathy in the Asian subcontinent, and Ayurveda and Yoga in the western world. Medical tourism has accelerated such diffusionary phenomena, which have in turn fueled its growth. In other cases however, it has slowed or reversed existing trends such as brain-drain, as working conditions back home have become more attractive. Such reversals have shifted the loci of existing policy problems and transplanted them to other pockets of the subsystem, requiring a different set of policy responses. For example, healthcare workers in countries like India, Malaysia and Thailand are increasingly migrating to the private sector to service foreign clients, leading to human resource shortages in the public health system, and forcing a rethink of domestic regulatory policies and human resource practices. Medical tourism has also brought to the forefront a number of practical difficulties, ranging from incompatibilities in medical norms and payment systems, to issues of contested citizenship and non-transferability of entitlements [8, 112‐115]. Such fault lines typically arise from cross-border heterogeneity in policy regimes, poor regulatory coordination and lack of cooperative frameworks. Yet, there is limited application of theoretical policy paradigms and comparative analysis in current medical tourism research. This article makes a plea for a comparative policy research agenda for medical tourism that recognizes the need for holistic evaluation of its differential effects in source and destination countries, acknowledges the diversity in national policy concerns and priorities, and deploys appropriate policy frameworks and theories to help discern its various challenges.